Vascular Ultrasound: Current state, current needs, future directions
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1 Vascular Ultrasound: Current state, current needs, future directions Laurence Needleman, MD Thomas Jefferson University Hospitals Sidney Kimmel Medical College of Thomas Jefferson University
2 Disclosures Member, Intersocietal Accreditation Commission Vascular Testing (unpaid)
3 Overview What tests are done for vascular disease? What is the natural history of vascular disease using ultrasound? What shortcomings exist for US vascular diagnosis? What is the future direction of ultrasound? of vascular ultrasound?
4 Gray scale ultrasound Carotid stent
5 Graphical representation of Doppler Makeup Doppler frequency or velocity - y axis Time - x axis Strength of signal - gray scale Number of reflectors Spectral Doppler
6 Color Doppler Carotid stenosis
7 Color Doppler Artifacts
8 Vein of Galen Aneurysm
9 Inferior Mesenteric Artery
10 Current state
11 Tests Venous ultrasound obstruction DVT Carotid duplex ultrasound - stenosis Aortic ultrasound - aneurysm Abdominal Doppler Renal arteries - stenosis Liver (portal hypertension) hypertension, flow direction Ovaries and testes increased or decreaed flow, tumors
12 Acting Surgeon General Issues Ca ll to Action to Prevent Deep Vein Th rom b os is a n d Pu lm on a ry Em b olis m FOR IMMEDIATE RELEASE Monday September 15, 2008 Contact: Office of Public Health and Science (202) Acting Surgeon General Steven K. Galson, M.D., M.P.H., today issued a Ca ll to Action to reduce the number of cases of deep vein thrombosis and pulmonary embolism in the United States. Galson urged all Americans to learn about and prevent these treatable conditions. Deep vein thrombosis and pulmonary embolism affect an estimated 350,000 to 600,000 Americans each year, and the numbers are expected to increase as the U.S. population ages. Together, deep vein thrombosis and pulmonary embolism contribute to at least 100,000 deaths each
13 Venous thromboembolic disease Ultrasound is the gold standard to diagnose deep venous thrombosis in the legs CT and NM are the major tests to diagnose its major complication, pulmonary embolism DVT and PE are associated with mortality, diagnosis of cancer, and chronic diseases
14 Venous US Normal Compression A A Vein
15 Noncompressible Vein: Causes Acute venous thrombosis (DVT) Scarring Inadequate compression Noncompressible Deep venous thrombosis Without compression With compression Acute Deep Venous Thrombus
16 Acute Venous Thrombosis Soft, deformable with compression Enlarges vein Smooth Free floating CFV Great saphenous vein Femoral vein
17 Initial -8mm +7 mos 4mm +11 mos 4mm +13 mos 9mm Popliteal vein recurrent thrombosis +45 mos 4mm
18 Virchow s Triad
19 Development of DVT depends on baseline risk and risk events Normal Thrombophilia
20
21 Duplex Doppler ultrasound is used to diagnose and grade stenoses Gray scale narrowing Color narrowing and color changes of elevated velocity Spectral Doppler in and beyond stenosis
22
23 Bournoulli and Stenosis Pre-stenosis Stenosis Post-stenosis Total energy = Kinetic + potential Potential energy very decreased Total energy lower Potential energy decreased Kinetic energy very increased
24 Increased Velocity in Stenosis
25 Pre and In the stenosis
26 Beyond the stenosis Change from small lumen to large lumen destabilizes flow Jet spreads out High velocity also destabilizing Frank breakdown of regular flow disturbed flow (and evenually turbulence)
27 Post Stenotic Disturbed Flow
28 Criteria for Stenoses Some circulations use absolute velocity Internal carotid artery Most circulations do not have standard velocities - Need ratios Some circulations use downstream effects in addition Peak systolic velocity ratio (velocity ratio) Highest velocity in stenosis divided by velocity proximal to stenosis (in normal vessel) IC:CC ratio PSV ratio in arteries Renal aortic ratio Intrarenal criteria
29 Abdominal aortic aneursym Abnormal dilatation of aorta If enlarges over 5 cm and is untreated, rupture may occur High mortality if rupture Approved for Medicare screening
30 Abdominal Aortic Aneurysm (AAA)
31 AAA gray scale ultrasound
32 AAA- Easy to measure, hard to acquire
33 Endoleaks
34
35 Natural history of atherosclerosis Preclinical disease Flow mediated dilatation, intima media thickness Location of plaque Clinical disease Degree of stenosis Plaque characterization Prediction of disease
36
37 Drawing of cross-sections of identical, most proximal part of six left anterior descending coronary arteries. Stary H C et al. Circulation. 1995;92: Copyright American Heart Association, Inc. All rights reserved.
38 Intima Media Thickness Used in epidemiological studies Strong predictor of future cardiovascular events Additive to some traditional cardiovascular risk factors Used in pharmaceutical studies How can it be applied to the individual? Reproducible clinically? How does it compare to other tests?e.g. history, lipids, CRP, CT coronary calcium scoring? One time or serial test?
39 O Leary et al NEJM 1999:340:14-22
40 Weird Doppler from the bulb
41 Flow separation
42
43
44 Plaque
45
46
47
48
49
50
51
52
53
54 This plaque is different
55
56 Current needs and problems
57 Calcifications and depth
58 PICA
59 PICA color
60 Before calcification
61 In
62 Distal 79 cm/s
63 Additional scanning
64 PSV 159, EDV 20, IC:CC 2
65 Duplex DSA Correlation Duplex Success Dark green best Light green Yellow Red worst Eiberg Eur J Endovasc Surg
66 Duplex Arteriography 1020 scans Not well visualized Iliac 73 Femoral 26 Popliteal 17 Infrapopliteal 221 Arterial wall calcifications 64 Poor runoff 18 Hingorani AP et al. Vascular 2008;16(3)
67 Solutions Better sonographers to find best direction CTA Future Multiplanar ultrasound Volume acquisition Volume flow (?) Sensitive techniques to low flow
68 Angle
69 Velocity requires angle correction
70 60 o Angle Correction 60 o 92.6cm/s 60 o 60 o 83.2cm/s 69.1cm/s
71 Angle errors worse for higher angles Table courtesy of Frank Miele
72 Angle Correction 60 o 92.6cm/s 50 o 90.9cm/s 70 o 122cm/s 88 o 4cm/s
73 What is angle?
74 Solutions Angle dependent scanning Multidirectional acquisition Less reliance on Doppler Gray scale modes
75 Is carotid ultrasound a public health problem? Same results in different laboratories give different degrees of stenosis
76 SRU Carotid Consensus Grant EG, et al. Radiology 2003;229:340.
77 World Federation Neurology
78 2002 ICAVL Survey 100 Vascular Labs 11 Different Criteria Unpublished data courtesy Ms. Sandra Katanick, Intersocietal Accreditation Commission
79 2010 ICAVL Survey 152 Vascular Labs; >16 Diagnostic Criteria
80 Future directions
81 Trifurcation of Ultrasound Point of care Traditional Ultrasound Personalized ultrasound (Specialized care) ER, primary care, some specialists Radiologists, some specialists Ultrasound specialist and team Problem centered, short duration Performed by doctor Protocol driven, more complete, Variable duration Performed by sonographer/vascular technologist, presented to doctor Detailed diagnostic or therapeutic scans, time depends on study but generally long (e.g. biopsy, contrast injection, therapy) Performed by doctor, usually with assistance (nurse, technologist)
82 Trifurcation of Ultrasound Future trends Point of care Traditional Ultrasound Personalized ultrasound Prettier pictures Few or no buttons Wireless acquisition and storage Simpler controls Volumetric acquisition Post processing Less dependency on sonographer skill (e.g. smart Doppler, protocols, angle independence, automatic measurements) Flow and pressure Contrast approval by FDA Drug delivery New modes with better macro and micro vasculature
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